(Aangegaan overeenkomstig artikel 3bis van de wet van 15 december 1980 betreffende de toegang tot het grondgebied, het verblijf, de vestiging en de verwijdering van vreemdelingen, hierna de wet van 15 december 1980, en overeenkomstig artikel 17/2 van het koninklijk besluit van 8 oktober 1981 betreffende de toegang tot het grondgebied, het verblijf, de vestiging en de verwijdering van vreemdelingen, hierna het koninklijk besluit van 8 oktober 1981) / (Endorsed in accordance with article 3bis of the law of 15 December 1980 regarding the access to the territory, the stay, the residence and the removal of foreigners, hereafter called the law of 15 December 1980, and in accordance with article 17/2 of the Royal Decree of 8 October 1981 regarding the access to the territory, the stay, the residence and the removal of foreigners, hereafter called the Royal Decree of 8 October 1981).

In voorkomend geval, de naam en het adres van de morele persoon in wiens naam of met wiens mandaat de verbintenis wordt aangegaan / If necessary, the name and address of the moral person in whose name or with whose mandate the formal obligation is endorsed :

By means of this formal obligation the guarantor, together with the foreigner, is during a period of two years severally liable for paying his/her costs for healthcare, stay and repatriation costs, from the day the foreigner legally entered the territory of the Member States of the Schengen area. As the occasion arises, the reimbursement of these costs is claimed by the State and the competent social service department, in accordance with the articles 17/7 to 17/9 of the Royal Decree of 8 October 1981.

The guarantor can only renounce this formal obligation if a new formal obligation, signed by another person, has been accepted, in accordance with article 17/2 of the Royal Decree of 8 October 1981, or if the foreigner is authorized or approved in another capacity for a stay on the territory.

If the formal obligation is endorsed in the framework of a visa application for a short stay, the data of the guarantor (name, first name and address), as well as, as the occasion arises, the data of the moral person (name and address) in whose name or with whose mandate the formal obligation is endorsed, need to be collected, in view of the examination of the visa application, in accordance with the Regulation (EC) n° 767/2008 of the European Parliament and the Council of 9 July 2008 concerning the Visa Information System (VIS) and the exchange of data between Member States on short-stay visas (VIS Regulation).

These data will be collected and stored during a maximum period of five years in the Visa Information System (VIS). During this period the data are accessible for the authorities charged with the visa, for the competent authorities charged with the control of the visa at the external borders and in the Member States, for the authorities that are competent for immigration and asylum in the Member States, in view of the control of the compliance with the conditions for the rightful entry and the rightful stay on the territory of the Member States, in view of the identification of the persons who do no longer comply with these conditions, in view of the examination of an asylum application and the determination of the authority that is responsible for this examination. Under certain conditions these data will also be accessible for the authorities that are indicated by the Member States and Europol, in view of the prevention and the detection of terrorist crimes and other serious criminal offences, also in view of the investigations on the subject.

In accordance with article 38 of the VIS Regulation the guarantor has the right:

to obtain communication of the data relating to him recorded in the VIS, and of the Member State which transmitted them to the VIS;

to request that data relating to him which are inaccurate be corrected;

to request that data relating to him recorded unlawfully be deleted;

to obtain information explaining the steps he can take to exercise the rights mentioned above, as well as the data of the national supervisory authorities where complaints regarding the protection of private date can be introduced.

The Belgian authority responsible for the treatment of these data is the Federal Public Service Home Affairs – Directorate-general Foreigner’s Office – Directorate Access and Stay, which is situated on the following address:

The decision by means of which the formal obligation is declared insusceptible or is refused, in accordance with article 39/2, § 2, of the law of 15 December 1980, is subject to an appeal for annulment at the Council for Aliens Disputes, that needs to be introduced within thirty days after the notification of this decision. A claim for suspension can be introduced in accordance with article 39/82 of the law of 15 December 1980. Except for the case of very urgent necessity both the claim for suspension and the appeal for annulment need to be introduced in one and the same deed.

Without prejudice to other legal and regulatory terms, the appeal mentioned above and the claim mentioned above are introduced by means of an application, that needs to meet the requirements mentioned in article 39/78 of the law of 15 December 1980 and in article 32 of the procedure regulation Council for Aliens Disputes. They are introduced at the Council by means of a registered letter, under the restriction of the derogations provided for by article 3, § 1, subsection 2 and 4, of the procedure regulation Council for Aliens Disputes, to the First President of the Council for Aliens Disputes, Gaucheretstraat 92-94, 1030 Brussels.

Under the restriction of the application of article 39/79 of the law of 15 December 1980, the introduction of an appeal for annulment and of a claim for suspension does not suspend the execution of the present measure.

Te /In …………………………………………………………

op / on…………………………………………………………………

Handtekening van de garant / Signature of the guarantor :

Deel II. Legalisatie(voorbehouden aan het gemeentebestuur van de verblijfplaats van de garant) / Part II. Legalization (reserved to the city council of the place of residence of the guarantor)

Gezien voor legalisatie van de handtekening van de garant / Seen for the legalization of the signature of the guarantor :

Te / In ……………………………………………………

op / on…………………………………………………………………

Handtekening van de burgemeester of zijn gemachtigde / Signature of the mayor or his/her deputy

STEMPEL / STAMP

Deel III. Beslissing(voorbehouden aan de Minister of zijn gemachtigde en aan de Belgische diplomatieke of consulaire post) / Part III. Decision (reserved to the Minister or his/her deputy and to the Belgian diplomatic or consular post)

De gelegaliseerde verbintenis tot tenlasteneming, aangegaan door de garant ten opzichte van de vreemdeling, wordt / The legalized formal obligation, endorsed by the guarantor with regard to the foreigner mentioned in part 1 is1 :

krachtens artikel 17/2 van het koninklijk besluit van 8 oktober 1981 aanvaard / under article 17/2 of the Royal Decree of 8 October 1981 regarding the access to the territory, the stay, the residence and the removal of foreigners, declared susceptible and accepted.

………………………………………………………………………………………………………………………………… of zijn gemachtigde / or his deputy.

De Belgische diplomatieke of consulaire post van / The Belgian diplomatic or consular post of ……………………………………………………………………

STEMPEL / STAMP

Deel IV. Bijzondere regels (voorbehouden aan het gemeentebestuur van de verblijfplaats van de garant) / Part IV. Particular rules (reserved to the city council of the place of residence of the guarantor)3

Aangezien de vreemdeling aan de visumplicht onderworpen is en de vraag wordt ingediend/zal worden ingediend bij de Belgische diplomatieke of consulaire post te / As the foreigner is subject to the visa requirement and the request is/will be introduced at the Belgian diplomatic or consular post in ………..

moet de verbintenis tot tenlasteneming gebruikt worden om het grondgebied van de Lidstaten van de Schengenruimte te betreden, overgelegd worden om de visumaanvraag te staven, en dit binnen een termijn van zes maanden, te rekenen vanaf de hierboven vermelde oproepingsdatum. Indien dit niet gedaan wordt, is de verbintenis tot tenlasteneming niet meer geldig / the formal obligation needs to be used to enter the territory of the Member States of the Schengen area/submitted to substantiate the visa application, and this within a term of six months, counting from the call date mentioned above. If this is not done, the formal obligation is no longer valid.

Handtekening van de Burgemeester of zijn gemachtigde / Signature of the mayor or his/her deputy

THE PRESENT FORMAL OBLIGATION IS ONLY A PROOF OF SUFFICIENT MEANS OF EXISTENCE BY THE FOREIGNER WITH REGARD TO WHOM IT IS CONCLUDED, WHEN IT IS LEGALIZED, DECLARED SUSCEPTIBLE AND ACCEPTED BY THE COMPETENT AUTHORITY.

1 Het juiste vakje aanvinken en, in voorkomend geval, de onnodige vermeldingen schrappen. In geval van onontvankelijkheid of van weigering van de verbintenis tot tenlasteneming de motieven in feite en in rechte vermelden, door de onnodige vermeldingen te schrappen en door in te vullen / Check off the right box and, if needed, delete needless mentions. In case of insusceptibility or of refusal of the formal obligation, mention the motives in law or in fact, by deleting the needless mentions and filling out.

2 De hoedanigheid van de Minister die de toegang tot het grondgebied, het verblijf, de vestiging en de verwijdering van vreemdelingen onder zijn bevoegdheid heeft aanduiden / Indicate the capacity of the Minister charged with the access to the territory, the stay, the residence and the removal of foreigners.

3 Het vakje dat overeenstemt met de situatie van de vreemdeling aanvinken / Check off the box that corresponds to the situation of the foreigner.

4 De Lidstaat van de Schengenruimte die België vertegenwoordigt aanduiden/ Indicate the Member State of the Schengen area representing Belgium.